剖宫产术后阴道分娩管理规范对剖宫产术后阴道分娩的指导价值

Value of clinical guidelines for vaginal birth after cesarean delivery

目的 探讨剖宫产术后阴道分娩（vaginal birth after cesarean,VBAC）的管理规范对安全开展和成功推行VBAC的指导意义. 方法 回顾性分析2009年1月至201 3年7月在同济大学附属第一妇婴保健院分娩的剖宫产术后再次妊娠的2 002例孕妇的资料,对本院VBAC管理规范实施前后试行VBAC的116例有1次剖宫产史的单胎孕妇进行比较,规范实施后的95例为研究组,规范实施前的21例为对照组.采用f或x2检验比较2组孕妇产后出血、子宫破裂、新生儿Apgar评分及入住新生儿病房等母儿结局. 结果 自2012年1月本院VBAC管理规范实施后,VBAC试产率从1.8％（21/1 147）增加至11.1％ （95/855）,VBAC成功率达97.9％（93/95）,仅2例因产时胎儿窘迫和活跃期停滞中转剖宫产终止妊娠.研究组孕妇产时出血[（246±127）ml]低于对照组[（260±35） ml]（t=0.50,P＞0.05）;产褥病率1例（1.0％）,高于对照组[0（0.0％）]（P＞0.05）;产后住院（2.1±0.8）d,短于对照组[（2.1±0.5）d]（t=0.22,P＞0.05）,但差异均无统计学意义.研究组新生儿出生体重为（3 290±632）g,显著高于对照组[（2 837±1 057）g]（t=2.59,P＜0.05）;新生儿l min Apgar评分8～l0分88例（92.6％）,4～7分7例（7.4％）,对照组21例新生儿1 min Apgar评分均为8～l0分（100％）,差异无统计学意义（x2=1.64,P＞0.05）;研究组1 7例（1 7.9％）新生儿入住新生儿病房,显著低于对照组[8例（33.1％）]（x2=4.15,P＜0,05）.2组均无子宫破裂、全子宫切除或母儿死亡等严重并发症. 结论 VBAC管理规范对安全开展VBAC和提高VBAC成功率有指导意义,有利于保障母儿安全和降低VBAC失败带来的严重不良预后.

Objective To assess the value of clinical guidelines for safe and successful implementation of vaginal birth after cesarean （VBAC）.Methods A retrospective study was conducted,which included 2 002 cases with prior cesarean delivery in the First Maternity and Infant Hospital Affiliated to Tongji University,from January 2009 to July 2013.A total of 116 women with singleton live births and one prior cesarean delivery who attempted VBAC were included.The cases were divided into two groups according to the time of implementation of the VBAC guidelines of our hospital：the research group （n=95） and the control group （n=21）.Pregnancy outcomes were evaluated according to whether the VBAC guidelines were implemented.Main outcome measures included the rates of attempting VBAC,postpartum hemorrhage,uterine rupture,neonatal Apgar score and admittance to neonatal unit.Chi-square or t-test were used to analyze the data.Results Following implementation of the VBAC guidelines from January 2012,the rate of trial labor increased to 11.1％ （95/855）,compared to 1.8％ （21/1 147） before implementation of the VBAC guidelines.In the research group,93 cases （97.9％,93/95） were successful in VBAC and only two cases failed due to fetal distress or a protracted active phase.The mean intrapartum blood loss in the research group was （246± 127） ml,which was lower than that in the control group [（260±35） ml,t=0.50,P＞0.05].Puerperal morbidity occurred in one patient （1.0％） in the research group,which was higher than that in the control group [0 （0.0％）] （P＞0.05）.The length of hospitalization in the research group was （2.1 ±0.8） d,which was longer than that in the control group [（2.1-±-0.5） d,t=0.22,P＞0.05].The neonatal 1 min Apgar score was 8-10 in 88 cases （92.6％） and 4-7 in seven cases （7.4％） in the research group; while the 1 min Apgar score in the control group was 8-10 in all 21 cases （100％） （x2=1.64,P＞0.05）.None of the above showed significant difference between the two groups.The mean neonatal birth weight in the research group was （3 290± 632） g,which was higher than that in the control group [（2 837±1 057） g,t=-2.59,P＜0.05].Seventeen neonates （17.9％） in the research group were admitted to neonatal units,which was lower than that in the control group [8 （33.1％）,x2=4.15,P＜0.05].There were no serious complications such as uterine rupture,hysterectomy or maternal death in the two groups.Conclusions The value of VBAC guidelines for the safe and successful implementation of VBAC is significant.These guidelines help to ensure maternal and fetal safety,and reduce serious complications caused by failed VBAC.